Oral Health Screening

Oral health is a basic component of children’s health,¹ and a particular concern in young newcomers to Canada. Newcomer status is itself a risk factor for early childhood caries (ECC),¹ and young newcomers may not have received dental care before their arrival or learned about oral hygiene in their country of origin.

Complications of early childhood caries:²

• Pain
• Difficulty chewing, which can  lead to poor feeding and slow weight gain
• Difficulty speaking
• Oral infections
• Loss of sleep, difficulty concentrating and interrupted learning
• Decay and loss of teeth
• Damage to permanent teeth
• Increased risk of caries development
• Increased risk of chronic inflammation and abscess formation

Because newcomers to Canada are more likely to first seek primary health care before dental care, paediatricians, physicians and other health care providers play an important role in screening and referral for dental care.³

Epidemiology

Many Canadian children have poor oral health: 57% of 6 to 11 year-olds and 59% of 12 to19 year-olds have (or have had) a cavity.⁴ However, the burden of illness disproportionately affects young newcomers, both in terms of oral health status and use of dental services.¹

Canadian data are limited, but U.S. and global data provide considerable insight on the state of oral health in young newcomers:^5,6

• One U.S. study of 366 refugee children found that 45% had dental caries, with the highest rates in children from Bhutan (50%), Burma (48%), Thailand (50%) and Malaysia (45%).
• Another study of 224 refugee children reported that 80% of children from Eastern Europe and 40% from Africa had experienced caries.
• Refugees have been found to have a higher rate of untreated decay than U.S.-born children (49% vs. 23%, respectively), despite having similar caries rates.

Figure 1: Dental caries levels in 12-year-olds worldwide

Source: Reproduced, with the permission of the publisher, from The World Oral Health Report 2003: The approach of the WHO Global Oral Health Program (Fig. 5, Page 11, accessed 14 January 2014).

Risk factors                                         

A number of risk factors for early childhood caries are particularly relevant to young newcomers:^1,7

• New immigrant status
• Lower income or parental education level
• Lack of a family dentist or of access to dental insurance or coverage
• Breastfeeding at frequent intervals
• Frequency snacking during the day
• A previous history of caries, plaques or demineralization
• Little or no exposure to fluoride

Screening and intervention

Young newcomers, especially refugees, may never have practiced oral health care (e.g., toothbrushing, fluoridated toothpaste or water) or received it from a dental professional before arriving in Canada.

The Canadian Collaboration for Immigrant and Refugee Health (CCIRH) have noted that, because physicians are often the first point of contact in the health care system for newcomers, they can play a key role in ensuring oral health through screening and referral.³ Their recommendations are summarized in Table 1.

Figure 2. White spot lesions

Source for Figures 2-5: Travis Nelson, DDS, MSD, MPH. Department of Pediatric Dentistry University of Washington. With permission.

Figure 3. Mild dental disease

Figure 4. Moderate dental disease

Figure 5.  Severe dental disease

All health providers can encourage and reinforce good oral health practices with newcomer families they see, by sharing these messages:

• Don’t put your baby or toddler to bed with a bottle or sippy cup – at night or at naptime.
• Minimize sugary foods and liquids (including juice and milk). A child doesn’t need to carry a bottle around between feedings.
• Teach children to drink from an open cup near first birthday.
• Never ‘sweeten’ a child’s a pacifier (soother) by dipping it in sugar or honey
• Don’t clean your child’s soother (or anything else she puts in her mouth) by putting it in your own mouth:  this can pass bacteria or viruses from mother to child

Information, educational materials and practice tools can be found on the Protecting All Children’s Teeth (PACT) Program website of the American Academy of Pediatrics.

• Parent handouts in multiple languages are available from the National Maternal and Child Oral Health Resource Center of Georgetown University.
• Helpful handouts on oral health topics are also available from:
  • Caring for Kids (the CPS website)
  • Health Canada
  • The Canadian Dental Association

Access to care

Dental care is not covered under the Canada Health Act, and lack of insurance coverage can be a barrier to accessing dental care for newcomer families.^7,8 One  study found that lack of dental care and insurance were the strongest predictors of caries in children younger than 7 years of age.⁷

Government funding for dental services for which young newcomers to Canada may be eligible is summarized below.  Publicly funded dental services tend to have a lower reimbursement scale than private coverage. Discrepancies between public and private reimbursement rates can lead to public patients not being accepted as readily by dentists.⁹

Federal dental coverage: The Interim Federal Health Program

Refugees and refugee claimants may be eligible for limited dental services under the Interim Federal Health Program. Program details can be found in the Health Insurance for Immigrant and Refugee Families section of this resource and on the Government of Canada website.

Provincial/territorial dental programs

Young newcomers to Canada may be eligible for dental funding assistance through a number of provincial or territorial programs,¹ as summarized in Table 2.  Many of these programs depend on the child having provincial/territorial health coverage, which may not include all newcomers, and refugee claimants in particular.

Other barriers

More information on how to recognize and address potential barriers to health care in newcomer patient and on using interpreters can be found on this website.

Selected resources

• The CPS position statement Oral health care for children – a call for action.
• The AAP’s web pages on Children’s Oral Health and their Protecting All Children’s Teeth Curriculum (PACT)
• The WHO’s web information on oral health.

References

1. Rowan-Legg A; CPS, Community Paediatrics Committee. Oral health care for children – a call for action. Paediatrics & Child Health 2013;18(1):37-43.
2. American Academy of Paediatrics. Oral Health and Protecting All Children’s Teeth Curriculum (PACT)
3. McNally M, Matthews D, Pottie K, for the Canadian Collaboration for Immigrant and Refugee Health. Evidence-based clinical guidelines for immigrants and refugees. Appendix 16: Dental disease; Evidence review for newly arriving immigrants and refugees. CMAJ 2011;183(12):E824-925.
4. Health Canada. Summary report on the findings of the oral health component of the Canadian Health Measures Survey 2007–2009. Ottawa, Ont.: Health Canada, 2010.
5. Cote S, Geltman P, Nunn M, et al. Dental caries of refugee children compared with U.S. children. Pediatrics 2014; 114(6):e733-40.
6. Shah A, Mitchell T, Oladele A. Nutritional status of refugee children entering DeKalb County, Georgia. J Immigrant Minority Health 2013 Jul 5 [Epub ahead of print].
7. Werneck RI, Lawrence HP, Kulkarni GV, et al. Early childhood caries and access to dental care among children of Portuguese-speaking immigrants in the city of Toronto. J Can Dent Assn 2008;74(9):805.
8. Newbold KB, Patel A. Use of dental services by immigrant Canadians. JCDA 2006;72:143a-f.
9. Bisgaier J, Cutts DB, Edelstein BL, et al. Disparities in child access to emergency care for acute oral injury. Pediatrics 2011;127(6):e1428-35.